Loft Rehab & Nursing of Normal

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician of a change in condition for one (R4) of six residents reviewed for change in condition in a sample list of 12. Findings Include:R4's Care Plan dated 6/14/2026 documents diagnoses of Sepsis, Intestinal Obstruction, Acute Kidney Failure, Metabolic Encephalopathy, Repeated Falls, Weakness, Peripheral Vascular Disease, Obstructive Sleep Apnea, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Reduced Mobility, Difficulty in Walking, and Traumatic Ischemia of Muscle. R4's Minimum Data Set, dated [DATE] documents R4 is moderately cognitively impaired. On 7/14/2026 at 10:25 a.m., V37 Hospital Nurse stated R4 entered the emergency room with stroke like symptoms, including left sided facial droop, left arm weakness, and slurred speech (on 7/5/26). [...]

Inspectors wroteBased on interview and record review, the facility failed protect the resident's right to be free from physical abuse by another resident for two (R2, R3) of three residents reviewed for abuse in a sample list of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain admission orders from the hospital upon admission, failed to complete a timely admission assessment and wound assessment, failed to timely administer medications for the treatment of a leg infection, diabetes, hypertension and other comorbidities and failed to provide mobility devices. The facility also failed to implement physical and occupational therapy evaluations upon admission which resulted in R1 having to stay in bed and use a bedpan for toileting needs. These failures affected one (R1) of three residents reviewed for admissions in the sample list of nine. These failures resulted in R1 sustaining ongoing, significant emotional distress, tearfulness and fear of a delayed recovery.

Inspectors wroteBased on interviews and record review the facility repeatedly failed to maintain complete and accurate medical records for one of three residents (R1) reviewed for admission/medical records on the sample list of nine.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote dignity for three (R6, R15, R20) of three residents reviewed for dignity in a sample of 23 residents. This failure resulted in R15 experiencing increased anxiety and becoming upset as V53 was overheard yelling/cussing (using foul language in a loud and derogatory manner) towards staff outside of R15's doorway. R6's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment. R6's Care Plan dated 10/18/2022 documents R6 is at potential risk for abuse due to Dementia. Despite R6's inability to comprehend interview questions, R6 was repeatedly observed independently propelling to and remaining near the nurse's station located by the facility's front door where V53 (Former Administrator), V32 Receptionist, and V41 Business Office Manager offices were located. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize and respond to a change in condition that required immediate intervention for two (R1, R8) of three residents reviewed for quality of care and failed to implement the physician's order for continuous oxygen therapy for one (R8) of three residents reviewed for oxygen in a sample of 23 residents. These failures resulted in R8 experiencing acute respiratory distress and being sent to the emergency department for hypoxia. R8 was diagnosed with Acute Respiratory Failure and Acute Congestive Heart Failure exacerbation. Findings Include:1. On [DATE] at 9:36 AM, R8 was observed lying in bed with oxygen at two (2) liters per minute via nasal cannula. R8 appears frail and opens and closes R8's eyes in response to verbal stimuli but does not answer questions or follow commands. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a full-time certified dietary manager. This failure has the potential to affect all 83 residents. Findings Include:On 03/23/26 at 10:15am, V17 Dietary [NAME] stated there was not a Certified Dietary Manager (CDM) when asked if there was a CDM.On 03/23/26 at 2:00pm, V43 Corporate Dietary Manager stated the facility employed a CDM V44 who works part time. On 03/24/2026 at 09:15am, V43 Corporate Dietary Manager stated the facility does not have a full time Certified Dietary Manager at this time. V43 stated V44 works every Tuesday, Thursday and Friday. On 03/24/2026 at 09:20am, R15 Resident Council President, stated the facility only has a part-time CDM and V44 is usually unavailable. On 03/24/2026 at 09:25am, Employee Roster review documents V44 CDM as a part-time employee. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow the menu as printed/posted. This failure has the potential to affect all 83 residents. Findings Include:On 03/23/2026 at 12:10pm, the posted lunch menu in the dining room documents Ravioli bake, Cauliflower, Bread Stick, Apple Orchard Bar and a beverage. On 03/23/2026 at 12:15pm, lunch observation was conducted in the main dining room. Residents received a main course of ravioli bake, Vegetable of the day was to be cauliflower which some residents received, some residents received mixed vegetables due to kitchen running out of cauliflower, no dessert was served on the tray at time of distribution. On 03/23/2026 at 12:20pm, conversations with random residents stated they would have preferred to have the cauliflower over the mixed vegetables and that the kitchen frequently runs out of various foods. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to hold and serve food at 135* Fahrenheit degrees or above. This failure has the potential to affect all 83 residents. Findings Include:On 03/23/2026 at 12:15pm, three (3) random lunch trays being plated at the serving window for resident consumption had a temperature of the ravioli bake taken at 108 degrees Fahrenheit. On 03/23/2026 at 12:15pm, lunch observation was conducted in the main dining room included the temperatures of random meal trays. One meal tray contained the main course of baked ravioli at a temperature of 95.3 degrees Fahrenheit. Another meal tray containing two (2) hamburger patties on buns, the hamburger meat recorded temperature 79.5 degrees Fahrenheit and the last tray temperature in the dining room contained cauliflower as the vegetable temperature of 86 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review the facility failed to serve the dinner meal during the posted time of 5:30pm to 6:30pm. This failure has the potential to affect all 83 residents. Findings Include:R11's Care Plan documents an admission date of 07/31/2025, care plan documents diagnosis of Anemia, Essential (Primary) Hypertension, Personal History of Other Venous Thrombosis and Embolism, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Gout, Localized Edema, Insomnia, Chronic Diastolic (Congestive) Heart Failure, Hyperlipidemia, Morbid (Severe) Obesity Due to Excess Calories, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Peripheral Vascular Disease. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff maintained professional standards of conduct, including accurate, truthful, and timely documentation in the medical record for four (R4, R7, R15, and R20) of four residents reviewed for falsification of records/reports for a total sample of 23 residents. Findings Include:Review of the Point of Care (POC) Audit Report printed on 3/27/2026 documents R4, R7, R15 and R20 were included on the list of residents that have missing documentation for Activities of Daily Living (ADL): Bathing on the POC Audit Report for the period of 1/5/2026 through 3/26/2026. On 3/31/2026 at 10:48 AM, V5 Certified Nurse Assistant (CNA) stated V5 was given a four-page list of residents V5 needs to complete retroactive documentation on. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform timely testing of residents with respiratory infection symptoms during a known Respiratory Syncytial Virus (RSV) outbreak for two of five residents (R3, R19) reviewed for infection control in the sample of 23 residents. Findings Include:On 3/25/26 at 9:07 am, V38 Assistant Director of Nursing (DON)/Infection Preventionist (IP) stated the facility had been in an RSV (Respiratory Syncytial Virus) outbreak which affected eleven residents. V38 DON/IP also stated that there was a delay in testing some residents because of agency staff using the wrong materials, which V38 caught after returning to work after the weekend. The ongoing Infection Control Log documents the first confirmed case of RSV on 2/20/26. [...]

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to prevent esophageal obstruction during medication administration by administering multiple medications at a time for one (R2) resident of three residents reviewed for medication administration on the sample list of three residents. This failure resulted in R2's esophagus becoming obstructed, with an inability to breath, the Heimlich maneuver was performed, and R2 was transferred to the local emergency room for further evaluation. Findings Include:Nursing Progress note dated 1/17/2026 at 8:00 PM documents at approximately 7:45 PM V13 Registered Nurse (RN) was called to room by a Certified Nursing Assistant (CNA) who reported the resident (R2) was not able to breathe. Writer entered room and observed the resident's lips being cyanotic; [...]

Inspectors wroteBased on Interview and Record Review the facility failed to answer a call light in a timely manner that resulted in a fall with injury for one (R1) resident of three residents reviewed for falls in a sample list of three residents. This failure resulted in R1 rolling from the bed, complaining of pain, requiring transfer to the local emergency room and diagnosed with multiple left and right rib fractures. Findings Include:R1's Progress Note written by V7 Licensed Practical Nurse dated 1/6/26 at 6:15 PM, documents R1 was observed lying face down between R1's bed and the wall. R1's roommate was yelling for help when the Certified Nurse Assistant entered the room and observed resident on the floor. It appeared R1 was reaching for something and rolled out of the bed. The bed was regular height. R1 was turned over carefully and R1's head was placed on a pillow. [...]

Inspectors wroteBased on interview and record review the facility failed to replace misappropriated goods in a reasonable time frame for one (R6) of three residents reviewed for abuse/misappropriation. R6 had to replace (iPhone) with R6's own personal money and the facility failed to report this to the state agency. Findings Include:On 1/5/2026 at 2:40PM, R6 reported that R6 was looking for R6's cellular device and couldn't find it. After looking through R6's room and in the dining room for the phone. V9 Registered Nurse stated at approximately 3:00PM on 1/5/2026, V9 notified R6's Power of Attorney and the facility Management of the missing phone. On 1/5/2026 at 7:34PM, V11 Normal Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. [...]

Inspectors wroteBased on Interview and record review the facility failed to report to state agency an allegation of misappropriated goods in a reasonable time frame for one (R6) of three residents reviewed for abuse/misappropriation of goods in a sample of three residents. Findings Include: On 1/5/2026 at 2:40PM, R6 reported to V9 Registered Nurse that R6 was looking for R6's cellular device and was unable to locate it after searching through R6's room and in the dining room/common area for the phone. V9 stated at approximately 3:00PM on 1/5/2026, R6's Power of Attorney and the facility Management was informed of R6's missing phone. On 1/5/2026 at 7:34PM, V11 local Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. [...]

Inspectors wroteBased on Interview and record review the facility failed to complete a thorough investigation of misappropriated goods in a reasonable time frame and failed to replace the misappropriated goods for one (R6) resident of three residents reviewed for abuse/misappropriation of goods in a sample of three residents. Findings Include: On 1/5/2026 at 2:40PM, R6 reported to V9 Registered Nurse that R6 was looking for R6's cellular device and couldn't find it after looking through R6's room and in the dining room. V9 Registered Nurse stated at approximately 3:00PM on 1/5/2026, R6's Power of Attorney and the facility management was informed of the missing phone. On 1/5/2026 at 7:34PM, V11 Local Police Officer documented V11 took a report over the phone for a theft that occurred at this facility. V11 called and spoke with V10 (R6's) Power of Attorney. [...]

Inspectors wroteBased on interview and record review, the facility failed to answer call lights in a timely fashion for three of three residents (R2, R7, R10) reviewed for call lights in the sample list of eleven. Findings Include:Grievance logs dated October 2025, November 2025 and December 2025 all document residents having to wait extended times for help with various activities. Resident Council Minutes dated 12/3/25 document 13 residents attended the meeting and documented staff need to answer call lights quicker. R2's Medical Record reviewed 12/30/25 documents R2 admitted to the facility on [DATE] from a local hospital with Diagnoses of Weakness, Right Sided Hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide showers for three (R1, R3 and R6) of five dependent residents reviewed for activities of daily living out of a sample list of eleven. Findings Include:R1's current Medical Record documents R1's admission to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis Right Ankle and Foot, Weakness, Chronic Atrial Fibrillation, and Chronic Kidney Disease Stage Four. R1's Care Plan includes a focus regarding ADL deficits initiated 04/11/2025. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. On 12/30/2025 at 9:42 AM R1 stated he received a bed bath last night with water staff retrieved from another area of the facility. R1 stated he had not received a shower or bed bath for approximately two weeks prior to last night's bed bath. R1 described his bed bath water as lukewarm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for four of four residents (R1, R2, R6, R9) reviewed for documentation in the sample list of eleven. Findings Include:On 12/30/25 R2's Medical Record review of Hospital Notes documents R2 admitted to the facility on [DATE] (unknown time) from a local hospital with Diagnoses of Weakness, right sided hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. The facility medical record does not contain an admission assessment or admission note with a time of arrival from a licensed nurse from time of arrival until discharge later on 11/24/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample list of eleven. Findings Include:On 12/30/25 the facility provided an investigation file dated 12/2/25 documenting a physical incident occurred between two roommates/residents (R8, R9). The file documents staff responded immediately, intervening to stop the interaction and separate the residents. R8's Current Care Plan reviewed on 12/30/2025 documents R8's admission to the facility on 5/1/2025 with the following diagnoses: Metabolic Encephalopathy, Protein-Calorie Malnutrition, Anemia in Chronic Kidney Disease, and Dementia in other Diseases, Moderate, with Agitation. [...]

Inspectors wroteBased on interview and record review the facility failed to assess a resident after an unwitnessed fall and failed to assist a resident off the floor following an unwitnessed fall for one (R3) of three residents reviewed for Quality of Care and Dignity on a sample list of five residents. Based on interviews with the family, this resident suffered psychosocial harm as a result of the resident being left on the floor.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was properly supervised to prevent a fall for one (R3) of three residents reviewed for accidents on a sample list of five.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was kept free from a significant medication error for one (R3) of three residents reviewed for medication management on a sample list of five residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their pest control policy for four residents (R3, R5, R12, R13) reviewed for Pest Control in the sample list of 15 residents. On 7/24/25 at 12:38 PM V6 Housekeeper stated V6 has seen roaches in the hallways and resident rooms, which started around March or April, and is most prominent on the Downtown [NAME] hallway. On 7/24/25 at 1:18 PM V8 Certified Nursing Assistant stated over the past year V8 has noticed roaches on the walls in hallways and resident rooms, mostly on the downtown west hallway. On 7/24/25 at 1:08 PM R3 attempted to enter R3's room. V3 Licensed Practical Nurse redirected R3 away from his room and told him his room was just sprayed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders for administration of eye drops for one of three residents (R3) reviewed for hygiene in the sample list of 15 residents. On 7/24/25 at 9:18 AM R3 was sitting in a wheelchair. R3's eyes were red with a small amount of yellow/white matter on the lower lids. R3 rubbed his eyes with his hands. At 1:03 PM R3's eyes had a small amount of matter on the lower lids. R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment. R3's active diagnoses list includes ectropion of right and left lower eyelids (drooping of eyelids). R3's Progress Note, recorded by V12 Nurse Practitioner, dated 4/10/25 documents R3 continues to have ectropion and chronic blepharitis (inflammation) to bilateral eyelids, Systane Complete ophthalmic solution ordered, continue current management. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wheelchair pedals were in place prior to propelling a resident in a wheelchair for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling from the wheelchair onto the tile floor and suffering a subarachnoid hemorrhage that required an overnight hospital stay. Findings Include: R1's Care Plan dated 05/09/2025 documents R1 is diagnosed with Dysphagia, Unspecified Psychosis, Dysarthria following Cerebral infarction, Hemiplegia, Muscle Weakness, Seizures, Major Depressive disorder, Unsteadiness on Feet, Other abnormalities of gait and mobility, lack of coordination, History of Falling, unspecified Dementia, and Diabetes. R1's Care Plan dated 05/09/2025 documents R1 is at risk for falling related to weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their infection prevention, response, and reporting policy following a newly identified Covid positive resident. This failure has the potential to affect all residents who reside in the facility. Findings Include: The 5/6/25 facility Census document 108 residents reside at the facility. R7's current diagnoses list includes the following diagnoses: Repeated Falls, Malignant Neoplasm of Prostate, COVID-19, Pain in Unspecified Joint, Abnormalities of Gait and Mobility, Type 2 Diabetes Without Complications, Chronic Atrial Fibrillation, Lack of Coordination, Colostomy, Hyperlipidemia, Vitamin C Deficiency. R7's progress note dated 4/14/2025 at 11:16 AM documents (R7) Tested positive for Covid; Power of Attorney here and was notified. Stated family member had tested positive and helped resident move in facility (4/11/25). [...]

Inspectors wroteBased on interview and record review the facility failed to document complete accurate assessments for one resident (R7) of three residents reviewed for documentation in a sample list of eight residents. Findings Include: R7's current diagnoses list includes the following diagnoses: Repeated Falls, Malignant Neoplasm of Prostate, COVID-19, Pain in Unspecified Joint, Abnormalities of Gait and Mobility, Type 2 Diabetes without Complications, Chronic Atrial Fibrillation, Lack of Coordination, Colostomy, Hyperlipidemia, and Vitamin C Deficiency. R7's progress note dated 4/11/25 at 7:30 PM documents R7 was admitted from the hospital emergency room following a fall at the assisted living facility where he lived on 4/11/25. R7's Nursing assessments on 4/11/25 and 4/12/25 do not indicate R7 was having any respiratory symptoms and documents R7 as negative for respiratory signs and symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the timeliness of laboratory services as ordered by a physician for one (R4) of one resident reviewed for laboratory services on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise care plans for two (R4 and R7) of three residents reviewed for care plan revision from a total sample list of 10 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for elopement risk, document the rational for application of an elopement notification bracelet, and re-apply an elopement notification bracelet after readmission from the hospital for one (R6) of three residents reviewed for elopement from a total sample list of ten residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination of ice, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food service equipment (sink) and floor areas. These failures have the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to permanently affix a narcotic lock box in a medication room for three of three residents (R68, R72, R40), reviewed for medication storage in the sample list of 41.

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect three residents (R83, R137, R187) of five reviewed for arbitration agreements on the sample list of 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain homelike room conditions for a resident room. This failure affects one resident (R61) of 24 reviewed for clean, comfortable, homelike environment in the sample list of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for a hearing-impaired resident (R73). This failure impacts one of one resident reviewed for impaired hearing in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete pressure ulcer treatments as ordered and failed to implement pressure relieving interventions for two of two residents (R138, R142) reviewed for pressure ulcers in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to check placement of a Gastrostomy tube (g-tube) prior to administering medications and prior to administering feeding for one of one resident (R138) reviewed for Gastrostomy tubes in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to place a resident in Enhanced Barrier Precautions for one of 24 residents (R142) reviewed for infection control in the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to safeguard one (R1) resident personal bank account entrusted to facility for billing purposes by withdrawing money from R1's account without R1's permission. This failure affects one (R1) out of three residents reviewed for resident funds in a sample list of four residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and homelike environment. This failure affects 36 residents (R4 through R39) reviewed for environment cleanliness on the sample of 39.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure for the safety and supervision of a resident with a history of self-harm and attempts at suicide. These failures affect one (R1) of three residents reviewed for behavioral health services on the sample list of three. R1 put a plastic bag tightly over R1's head resulting in emergency transport to the hospital, previously R1 was found on 5/20/24 with the call light cord wrapped around her neck. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/20/24 when R1 was found with the call light cord wrapped around R1's neck. R1 had continued access to self-harm items resulting in another attempt on 7/10/24. On 7/31/24 at 12:15 PM, V1 Administrator was notified of the Immediate Jeopardy situation. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a severely cognitively impaired resident (R1) did not exit the facility unnoticed (elopement). The facility failed to reassess and develop a plan of care for a resident with a known history of exit seeking behaviors, wandering, and supervision needs during emergency procedures. These failures affect one (R1) resident reviewed for elopement on a sample list of three residents. These failures resulted in R1 exiting the facility in the late afternoon on 5/31/24, unsupervised, being found 17 hours later in a grassy area next to a creek. R1 had potential for serious injury and/or death due to poor safety awareness in negotiating city streets/traffic and environmental hazards including a crossing four lanes of traffic to arrive at a nearby creek with dense brush, rugged terrain in the dark. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to accurately transcribe hospital discharge medication orders for a resident (R37) with a seizure disorder, ensure medications were available for administration, and ensure contracted nurses have access to the backup medication supply. These failures resulted in R37 missing 13 doses of medications to control seizures: 9 doses of Divalproex Sodium, 2 doses of Levetiracetam and 2 doses of Carbamazepine; being hospitalized experiencing continued seizures and requiring intravenous seizure medication. R37 is one of three residents reviewed for hospitalizations in the sample list of 47. The Immediate Jeopardy began on 9/7/23 when R37's hospital discharge orders for Divalproex Sodium were transcribed incorrectly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a resident's nutritional and hydration status to prevent a significant weight loss and dehydration. The facility failed to: follow physician orders for monitoring enteral feeding (via gastrostomy tube) intake amounts for a resident who has care orders for nothing by mouth and ensure for placement of the resident's abdominal binder. The facility also failed to follow up with the physician and implement dietary recommendations or notify the Registered Dietician and/or Physician of the inability to obtain the recommended enteral feedings in a timely manner. The facility failed to obtain weights timely for an accurate/baseline nutritional assessment to be completed and to ensure residents enteral feeding was being administered as ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe and implement physician orders to promptly send a resident to the hospital with a change in condition and failed to recognize a change in condition for one of two residents' (R78) reviewed for skin conditions on the sample list of 47. This failure resulted in a delay of hospitalization/treatment for R78. Upon admission to the hospital for worsening Gangrene of the right foot/toe, R78 was diagnosed with Osteomylitis and Sepsis due to Osteomylitis requiring Intravenous Antibiotics, an above the knee popliteal bypass grafting and amputation of the third right toe. Findings Include: On 9/17/23 at 10:13 AM, R78 was lying in bed. R78's right third toe was black, to the base of the toe, with red skin coloring at the base of the toe, on the top of the foot extending approximately 2 cm (centimeters). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement residents' pressure relieving interventions to prevent the development of pressure ulcers, and report pressure ulcers to the nurse so a treatment order could be obtained. This failure affects one of two residents (R139) reviewed for pressure ulcers on the sample list of 47. This failure resulted in R139 developing four, stage two pressure ulcers. Findings Include: R139's MDS (Minimum Data Set) dated 9/1/23 documents R139 is alert and oriented and requires extensive assistance of one staff for transfers. R139's Skin Risk assessment dated [DATE] documents R139 is at risk for breakdown. [...]

Inspectors wroteBased on interview and record review, the facility failed to document timely and specific actions following receipt of resident grievances. This failure has the potential to affect all 85 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary kitchen pantry floor areas. This failure has the potential to affect all 85 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 85 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document resident infections and antibiotic treatments as required, failed to ensure antibiotic prescriptions were limited to residents meeting nationally recognized surveillance criteria, and failed to document residents' responses to antibiotic therapy. This failure affects R23, R27, R62 and has the potential to affect all 85 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employee a full time Infection Preventionist per the Facility Assessment. This failure has the potential to affect all 85 residents who reside at the facility. Findings Include: The Facility assessment dated [DATE] documents the facility will have a full time DON (Director of Nursing), ADON (Assistant Director of Nursing), MDS (Minimum Data Set)/Care Plan Coordinator, and Infection Preventionist Nurse, all separate positions. On 9/25/23 at 11:20 AM, V1 Administrator stated V2 DON was the Infection Preventionist until taking over as DON on 8/28/23, so V2 is currently doing both jobs, as the facility does not have a separate Infection Preventionist. V1 confirmed the Facility Assessment documents the Infection Preventionist and DON will be separate positions. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely complete comprehensive MDS's (Minimum Data Set's) for four of 44 residents (R40, R139, R17, R48) reviewed for resident assessments on the sample list of 47. Findings Include: The facility Resident Assessment Policy dated 9/12/19 documents the facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS (Centers for Medicare and Medicaid Services). 1. R40's ongoing Census documents R40 was admitted to the facility on [DATE]. As of 9/18/23, R40 does not have a completed comprehensive MDS (Minimum Data Set). On 9/18/23 at 12:43 PM, V11 MDS/Care Plan Coordinator confirmed R40's Comprehensive admission MDS has not been completed yet and stated, it should be completed within 14 days after admission. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop comprehensive care plans to include a urinary catheter, antidepressant medication, anticoagulant medication, CPAP (Continuous Positive Airway Pressure), and seizure disorder for four (R64, R1, R20, R37) of 18 residents reviewed for care plans in the sample list of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise comprehensive care plans to reflect the resident's current needs/condition and failed to conduct care plan meetings with residents and resident representatives for four of 44 residents (R40, R72, R78, and R75) reviewed for care plan revisions and meetings on the sample list of 47. Findings Include: The facility's Care Planning, Resident Participation Policy dated 9/12/19 documents the facility supports the resident's right to be informed of and participate in his or her care planning and treatment. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer tube feeding at the ordered rate, timely follow up and implement dietitian recommendations for tube feeding rate and water flushes, document routine checks of tube feeding placement and residual volumes, and record tube feeding, and water flush volumes administered for one (R286) of two residents reviewed for gastrostomy tubes in the sample list of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform suctioning of a tracheostomy under sterile conditions and according to facility policy, failed to have an ambu bag at the bedside for a resident with a tracheostomy, and failed to prevent potential contamination of a BiPAP Machine for four of four residents (R44, R75, R20, R286) reviewed for respiratory care on the sample list of 74. Findings Include: The Facility CPAP/BiPAP Cleaning Policy dated 9/1/20 documents it is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC (Centers for Disease Control) guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. Clean the mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent for an antidepressant for one (R1) of five residents reviewed for unnecessary medications in the sample list of 47.

Inspectors wroteBased on interview and record review, the facility failed to provide an Advanced Beneficiary Notice upon resident discharge from Medicare Part A services. This failure affects two residents (R24, R78) of three reviewed for beneficiary protection notifications in the sample list of 47.

Inspectors wroteBased on interview and record review, the facility failed to provide resident privacy while performing personal cares. This failure affects two residents (R33, R50) of 44 reviewed for privacy in the sample list of 47.

Inspectors wroteBased on interview and record review the facility failed to provide written bed hold notification for one (R1) of three residents reviewed for hospitalizations in the sample list of 47.

Inspectors wroteBased on interview and record review the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed to include the use of an anticoagulant for one (R20) of five residents reviewed for unnecessary medications in the sample list of 47.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a baseline Care Plan was completed accurately to include the use of a urinary catheter for one (R64) of one resident reviewed for urinary catheters in the sample list of 47.

Inspectors wroteBased on observation, interview and record review the facility failed to provide services to a resident requiring extensive assistance with transferring from a wheelchair. This failure affects one resident (R139) reviewed for Activities of Daily Living assistance on the sample list of 47. Findings Include: R139's MDS dated [DATE] documents R139 is alert and oriented and requires extensive assistance of one staff for transfers. On 9/17/23 at 11:30 AM, R139 was sitting up in a wheelchair and stated staff got R139 up around 7:00 am for breakfast and refuse to lay R139 down until after lunch. On 9/17/23 at 1:30 PM, R139 remains sitting up in the wheelchair in R139's room. R139 stated staff still have not laid R139 down after requesting to be laid down several times. On 9/18/23 at 9:54 AM, R139 was sitting up in a wheelchair in R139's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to safely store an oxygen cylinder for one of two residents (R9) reviewed for oxygen on the sample list of 47. Findings Include: On 9/17/23 at 9:42 AM, an oxygen cylinder was lying across a wheelchair seat in R9's room, unsecured. At this time, V4 LPN (Licensed Practical Nurse) stated the oxygen cylinder was for R9 who was hospitalized a few days ago. V4 also stated the oxygen cylinder isn't supposed to be like that, it should be secured. V4 then exited R9's room without securing the oxygen cylinder. R9's ongoing Census documents R9 was hospitalized on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and record fluid intake and implement dialysis recommendations/orders for one (R1) of one resident reviewed for dialysis in the sample list of 47.

Inspectors wroteBased on interview and record review, the facility failed to document a medical necessity for prescribing antibiotic medications. This failure affects three residents (R23, R27, R62) of three reviewed for unnecessary antibiotics in sample list of 47.

Inspectors wroteBased on observation, interview, and record review the facility failed to post signage and implement transmission-based precautions during nebulizer administration for one (R286) of two residents reviewed for tracheostomy in the sample list of 47.

Inspectors wroteBased on record review and interview the facility failed to protect the resident's (R53) right to be free from verbal and mental abuse by another resident (R10). R53 and R10 are two of four residents reviewed for abuse on the sample list of 32.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure food was protected from potential cross contamination, failed to ensure food was stored in a manner to assure sound condition, safety, and quality, and failed to maintain food contact surfaces in a clean, sanitary condition. These failures have the potential to affect all 81 residents residing in facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility employed a licensed administrator. This failure affects all 81 residents residing in the facility.

Inspectors wroteBased on record review, observation and interview the facility failed to prevent the spread of COVID-19 by not following their COVID-19 testing policy for one (R66) resident, failed to wear Personal Protective Equipment (PPE) while providing care for two COVID-19 positive residents for one resident (R58, R60 ), failed to properly dispose of contaminated Personal Protective Equipment (PPE) for one resident (R58) and failed to ensure contaminated linen and garbage from COVID-19 positive residents was disposed of properly. These failures affected four residents (R20, R58, R60 and R66) out of 17 residents reviewed for infection control in a sample list of 32 residents.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure dignity was maintained by failing to allow residents to eat in the dining room and failed to provide appropriate plates and cutlery during meal service. These failures affected four residents (R13, R24, R52 and R53) of seven residents reviewed during dining on the sample list of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for one of one resident (R66) reviewed for self-administration of medication on the sample list of 32. Findings Include: The facility policy Resident Self-Administration of Medication dated 07/01/2021 documents the following: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. [...]

Inspectors wroteBased on record review and interview the facility failed to operationalize their abuse prevention policy by failing to prevent resident to resident verbal and mental abuse, failing to recognize a resident-to-resident altercation as potential abuse and failing to report an allegation of abuse immediately to the state survey agency. These failures affect two of four residents (R10 and R53) reviewed for abuse on the sample list of 32 residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of verbal and mental abuse immediately to the state survey and certification agency. This failure affects two of four residents (R10 and R53) reviewed for abuse on the sample list of 32 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) screening was completed for two (R41 and R59) out of two residents reviewed for PASARR screenings in a sample list of 32 residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure R43's surgical wound dressing and diabetic ulcer dressing were changed daily as the physician ordered. The facility also failed to maintain documentation of R43's weekly wound measurements. These failures affected one of three residents (R43) reviewed for wounds on the sample list of 32.

Inspectors wroteBased on record review, observation and interview the facility failed to prevent cross contamination during pressure sore treatments for one (R20) resident out of three residents reviewed for pressure ulcers in a sample list of 32 residents.

Inspectors wroteBased on record review, observation and interview the facility failed to implement a post fall intervention for a resident (R75) at high risk for falls with a history of falls. R75 is one of two residents reviewed for falls/accidents on the sample list of 32.

Inspectors wroteBased on record review, observation and interview the facility failed to prevent cross contamination during urinary catheter care for (R20) and failed to measure urinary output in accordance with facility policy for (R69). R20 and R69 are two of two residents reviewed for indwelling urinary catheters on a sample list of 32 residents.

Inspectors wroteBased on record review and interview the facility failed to include a Care Plan for Renal Dialysis and failed to ensure Renal Dialysis communication was completed and documented with each Renal Dialysis session for R287, one of two residents reviewed for Renal Dialysis in a sample list of 32 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error by failing to follow the physician ordered time of administration, directives for clinical staff to administer medication, and by failing to follow the medication administration policy to observe resident consumption of medication. These failures affected one of ten residents (R66) observed during medication administration in the sample list of 32. Findings Include: R66's Physician Order Summary Report Sheet (POS) dated 12/16/22 documents the following diagnoses: Hypertensive Chronic Kidney Disease With Stage Five Chronic Kidney Disease or End Stage Renal Disease and Dependence on Renal Dialysis. The same POS documents the following physician ordered medications: [...]

Inspectors wroteBased on interview and record review, the facility failed to have the required committee members present at one Quality Assessment and Assurance (QAA) meeting of the four quarterly meetings for the year. This has the potential to affect all 81 residents in the facility.